Logan, Edward g 4 /t 3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Se
rd R L�9«..;-, 4 /
Date of Death Age If Veteran'of U.S. med Forces,
5 —1O �Lp _7 7 War or Dates /sL7
}- Place of Death Hospital, Institution or /� "�
6 City- ow or Village aut,,,5buni Street Address � I-_a_ .-rel JA▪ Manner of Death Natural Cause 0 Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ill Circumstances Investigation
u Medical Certifier Name Title
n 01 L.t n n, r3 h(y,., l\-1
Address
3 I rD 0 fr k 6l9403 / // Ay
Death Certificate Filed Dist tt Number RegisterNumber
City,�fow�r,or Village (�{ ,jl�jb(�19 S
❑Burial Date J Cnetery or Cremat
❑Entombment 5" /2 " i(el T"i ne V l e iD v-tol'�.
Address
lCremation PULti 3b1(r2 if
/
Date ,� Place Removed
Z❑Removal and/or Held
and/or Address
H Hold
ta
O Date Point of
to Li Transportation Shipment
O by Common Destination
Carrier
M IDDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home A.4 i /Ie r —r e.,r'Ct 1 4Oh'r, 0 /C 9q
Address 057 ;\J 5 r tt 50 ))yi ict I. oi. } , IZ�4-
" Name of Funeral Firm Maki g Disposition osition or to Whom
14, Remains are Shipped, If Other than Above
Z Address
it
la
! Permission is her by granted to dispose of the human remains described above- as indicated.
Date Issued 5')2, 1(p Registrar of Vital Statistics Ia(-� Cf.
, l-L_Q 4-3v_
(signature)
District Number (( / Place" (,Lv r15bt,(_al, MI
v were disposed of in adcordance with this permit on:
I certify that the remains of the decedent identified above p
Z
LEI Date of Disposition S'(6�/t Place of Disposition iq )-... � .i'6--
2 (address)
LEI
Cl)
L (section) (lot number) (grave number)
ta Name of Sexton or Person in Charge of remises r
please print)
LEI
Signature Title (afrttPk
(over)
DOH-1555 (02/2004)